Objective To compare tension-free vaginal tape with colposuspension as primary treatment for stress incontinence. Design Multicentred randomised comparative trial. Setting Gynaecology or urology departments in 14 centres in the United Kingdom and Eire, including university teaching hospitals and district general hospitals. Participants 344 women with urodynamic stress incontinence; 175 randomised to tension-free vaginal tape and 169 to colposuspension Main outcome measures Assessment before treatment and at six months postoperatively with the SF-36, the Bristol female lower urinary tract symptoms questionnaire, the EQ-5D health questionnaire, a one week urinary diary, one hour perineal pad test, cystometry, and, in some centres, urethral profilometry. Results 23 women in the colposuspension group and 5 in the vaginal tape group withdrew before surgery. No significant difference was found between the groups for cure rates: 115 (66%) women in the vaginal tape group and 97 (57%) in the colposuspension group were objectively cured (95% confidence interval for difference in cure − 4.7% to 21.3%). Bladder injury was more common during the vaginal tape procedure; postoperative complications, in particular delayed resumption of micturition, were more common after colposuspension. Operation time, duration of hospital stay, and return to normal activity were all longer after colposuspension than after the vaginal tape procedure. Conclusion Surgery with tension-free vaginal tape is associated with more operative complications than colposuspension, but colposuspension is associated with more postoperative complications and longer recovery. Vaginal tape shows promise for the treatment of urodynamic stress incontinence because of minimal access and rapid recovery times; cure rates at six months were comparable with colposuspension.

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CONTEXT: Retropubic (RT-TVT) and transobturator miurethral (TO-TVT) mid-urethral sling (MUS) are popular surgical treatments for female stress urinary incontinence (SUI). The long-term efficacy and safety of the procedures is still a topic of intense clinical research and several randomized controlled trials (RCTs) have been published in the last years OBJECTIVE: To evaluate the efficacy and safety of MUS compared with other surgical treatments for female SUI. EVIDENCE ACQUISITION:A systematic review and meta-analysis of the literature was performed using the Medline, Scopus, and Web of Science databases to update our previously published analyses. EVIDENCE SYNTHESIS:Twenty-eight RCTs were identified. In total, the meta-analyses CONCLUSIONS:The present analysis confirms the superiority of MUS over BC. The studies comparing insertion of RT-TVT and TO-TVT showed higher subjective and objective cure rates for the RP-TVT but at the cost of higher risks of some complications and voiding LUTS. Efficacy of 3 inside-out and outside-in techniques of TO-TVT insertion was similar, although the risk of vaginal perforation was lower in the inside-to-out TO-TVT. PATIENT SUMMARY:Retropubic and transobturator midurethral slings are a popular treatment for female stress urinary incontinence. The available literature suggest that those slings are either more effective or safer than other older surgical procedures. Retropubic tapes are followed with slightly higher continence rates as compared with the transobturator tapes but are associated with higher risk of intra-and postoperative complications. TAKE-HOME MESSAGESThe present analysis confirms the superiority of MUS over Burch colposuspension. The studies comparing insertion of RT-TVT and TO-TVT showed higher subjective and objective cure rates for the RP-TVT but at the cost of higher risks of some complications and voiding LUTS. Efficacy of inside-out and outside-in techniques of TO-TVT insertion was similar, although the risk of vaginal perforation was lower in the inside-to-out TO-TVT 4

Objective To compare the long-term outcomes of tension-free vaginal tape (TVT) and colposuspension as primary treatment for stress incontinence.Study design Multicentre randomised controlled trial.Setting Secondary and tertiary care gynaecology, urology and urogynaecology departments in 14 centres in the UK and Eire.Population Women with urodynamically confirmed stress incontinence and who had previously failed to respond to conservative treatment were invited to participate.Methods Three hundred and forty-four women were randomised; 175 to TVT and 169 to colposuspension. This paper reports the 5-year outcomes.Main outcome measures The primary outcome at 5 years was a 1-hour perineal pad test; other outcomes included clinical examination, Short Form-36 (SF-36) health status and Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaires.Results A negative 1-hour pad test was recorded in 58/72 (81%) women in the TVT group and 44/49 (90%) in the colposuspension group (P = 0.21, Fisher's exact test) at 5 years. There was an increase in enterocoele and rectocele in the colposuspension group; three late tape complications were seen in the TVT group.Conclusion This study did not detect a significant difference between TVT and colposuspension for the cure of stress incontinence at 5 years. The effect of both procedures on cure of incontinence and improvement in quality of life is maintained in the long term. Vault and posterior vaginal wall prolapse are seen more commonly after colposuspension. Tape erosion may occur several years after surgery.

The aim of the study was to determine the epidemiological background, clinical details and surgical outcome of patients presenting with urogenital fistulae to St Luke's Hospital, Uyo, and the associated VVF Unit at Mbribit Itam, Akwa Ibom State, Nigeria, between January 1970 and December 1994. A retrospective review of hospital operating theater records and case notes was carried out. Clinical details and outcome were assessed for the total cohort of 2484 patients. Epidemiological data were extracted from the case notes of 715 patients presenting between January 1990 and December 1994. Of these 92.2% were of obstetric etiology, 80.3% following neglected obstructed labor, 6.9% following cesarean section, and 5.0% followed ruptured uterus; 4.4% followed pelvic surgery and the remaining 3.4% of miscellaneous causes included malignancy, coital injury, infection and trauma; 8% had a coexisting rectovaginal fistula or third-degree perineal tear. Only 37.3% of patients were aware of their age; the median age of this group was 28 years. Literacy was difficult to judge reliably, although 29% were able to sign their name. Parity ranged from 0 to 17, and only 31.4% of fistulae related to first pregnancies. Although 73.1% were delivered in hospital, in 97.1% labor was initially managed at home, with a traditional birth attendant, in a maternity home, or in church; 34.1% were delivered by cesarean section, although the live-birth rate was only 10.3% in the causative pregnancy. For a variety of reasons 124 women were not operated upon: 1954 underwent only one operation, giving a presumptive cure rate at first operation of 81.2%; 247 underwent two, 116 three, 32 four, and 11 five operations during the study period. The ultimate closure rate was 97.7%, with only 0.6% undergoing urinary diversion. The type and distribution of fistulae recorded in this series is consistent with previous series of largely obstetric fistulae from the developing world. Surgical cure rates are also comparable. The epidemiological background is at variance with previous reports in several respects; this may reflect biosocial differences in the population studied.

Summary. Urethral pressure measurements were recorded at rest and during stress by a microtransducer technique in 20 women without urinary symptoms and 120 women with urodynamically proven genuine stress in‐continence. In the symptom‐free women the resting profile values were largely maintained during stress, as a consequence of 100% transmission of intra‐abdominal pressure rises to the proximal three‐quarters of the functional urethral length. Whilst the majority maintained continence at the bladder neck level, 25% of these controls showed evidence of bladder neck opening during stress. The stress‐incontinent patients showed a deficiency of pressure transmission ratios which appeared to have an ‘all or none’ character in the determination of symptoms. The amplitude and stability of the maximum urethral closure pressure at rest, the extent of urethral closure pressure lost in response to stress, and the extent of intra‐abdominal pressure rises interact to determine the severity of symptoms or ‘margin to continence’.

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Vesico-vaginal fistula remains a major public health issue in the developing world. Over 80% of cases result from neglected obstructed labour, and the condition may follow 1-2 per 1000 deliveries, with an annual worldwide incidence of up to 500,000 cases. The principles of investigation and treatment are reviewed in this paper, although national and international strategies aimed at prevention are much more important to the ultimate eradication of this devastating condition. Such strategies much include government recognition of fistulae as a major public health concern, improvement in the status of women in society, the extension of primary education particularly for girls, and affordable, accessible and acceptable services for all pregnant women.